Patient intake form template

A free patient intake form template in Word and PDF for small practices like PT, chiropractic, massage and counseling, plus what HIPAA may mean for you.

Signed by: Patient, then Parent or Guardian (if the patient is a minor).

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When SignWren launches, you'll be able to customize this template, save it to your own account and send it for e-signature. Join the waitlist to hear first.

Free, no sign-up. Updated September 30, 2026 by Suresh Ganapathy.

A patient intake form is the paperwork a new patient fills in before their first appointment: who they are, how to reach them and someone close to them, how they’ll pay, and enough health history for you to treat them safely. This free template is built for small practices, the kind of physical therapy, chiropractic, massage or counseling office where one person handles scheduling, forms and the front desk. Download it in Word or PDF and cut it down to what you actually use.

When do you need a patient intake form?

You need one any time you take on a new patient or client and want their details and history in writing before you start. Most practices send it ahead of the first visit so the patient can fill it in at home, with their medication list and insurance card in front of them, instead of on a clipboard in the waiting room.

It’s not the right document for everything. If you’re about to perform a specific treatment or procedure and want the patient to confirm they understand the risks, that’s an informed consent form. If you run group fitness classes or an activity where people could get hurt, you probably want a release of liability waiver as well. Plenty of practices use all three.

What should a patient intake form include?

A good intake form collects what you need and nothing more. Here’s how our template is laid out and why each part is there.

Patient information. Full name, date of birth, address, phone and email, plus a preferred contact method. That last one matters more than people think: some patients don’t want voicemails at work.

Emergency contact. Name, relationship and phone number. Simple, but you’ll be glad you asked the one time you need it.

Referral and reason for visit. Who referred them (a physician, a friend, a search) and, in their own words, what brought them in. For a PT or chiropractic office this is where the patient describes the injury, when it started and what makes it worse.

Insurance or payment. Insurance carrier, member ID and policyholder, or a checkbox for self-pay. Cash-only practices can delete the insurance lines entirely.

Assignment of benefits (optional). If you bill insurance for the patient, this short section lets them authorize you to send claims and release the information the insurer needs, and to have the insurer pay you directly. It also reminds them they still owe whatever insurance doesn’t cover. Self-pay practices can delete it.

Health history. Current medications, allergies, past surgeries, existing conditions from a short checklist, and a free-text box for anything else. Keep the checklist relevant to what you do. A massage therapist needs to know about blood clots and recent surgeries; they don’t need a full family history.

Practice policies. Your cancellation and no-show policy, payment terms, and how you’ll communicate with the patient. Say it plainly so nobody is surprised by a late-cancel fee.

Privacy notice acknowledgment. A line where the patient confirms they received your notice of privacy practices. If you’re a HIPAA covered entity, you’re expected to make a good faith effort to get this acknowledgment in writing (more on that below).

Accuracy statement and signature. The patient confirms the information is accurate and that they’ll tell you if it changes. Then they sign and date it. For a minor, a parent or guardian signs in the separate block below the patient’s.

Does HIPAA apply to your patient intake forms?

An intake form collects health information, and HIPAA may cover that information if your practice is a covered entity. According to HHS, health care providers such as doctors, clinics, psychologists, dentists and chiropractors are covered entities “only if they transmit any information in an electronic form in connection with a transaction” for which HHS has adopted a standard. In practice that usually means things like billing insurance electronically. A cash-only massage studio might not be a covered entity at all. A PT clinic that submits claims almost certainly is. Read the HHS covered entity page and decide with a compliance advisor, not a blog post.

If you are covered, two things follow for your forms. First, HHS says a covered provider with a direct treatment relationship must make a good faith effort to get the patient’s written acknowledgment that they received your notice of privacy practices, which is why our template has that line. Second, any outside company that stores or handles the completed forms for you (a cloud drive, a form builder, an e-signature service) is likely a business associate, and HHS requires a written business associate agreement (BAA) with them.

Here’s the honest part: SignWren is not yet set up to handle HIPAA-covered data and does not sign BAAs. If you’re a covered entity, don’t use SignWren for patient intake forms. Use a tool that will sign a BAA with you.

How do you fill it in and get it signed?

For a small chiropractic office with a new patient booked for Thursday, a workable routine looks like this:

Open the Word version and put your practice name, address and phone at the top.
Rewrite the policies section with your real cancellation window and fees.
Trim the health history checklist to conditions that change how you treat someone.
Save it as a PDF and send it to the patient a day or two before the visit.
The patient fills it in and signs. Review it before they arrive, not while they’re on the table.
Store the signed copy with the rest of their record, and give the patient a copy if they ask.

Electronic signatures on intake forms are generally fine. Federal law and nearly every state treat an e-signature as valid for most documents, as we explain in are electronic signatures legally binding. The catch in healthcare is rarely the signature itself; it’s where the signed form lives and who can see it. For a covered entity that means a tool with a BAA. For a practice that isn’t covered, it still means treating the form as private: limit who has access, and don’t email completed forms around the office.

If your practice isn’t a covered entity, you can download it, fill in the blanks, and send it for e-signature with any tool you like. (SignWren isn’t live yet, but it’s being built for paperwork like this; the waitlist is here.)

This template is general information, not legal advice. For your specific practice, talk to a lawyer or compliance professional licensed where you are.

The new patient intake form template

Download as Word

Template from signwren.com. General information, not legal advice. Check your state's rules and adapt it before you use it.

NEW PATIENT INTAKE FORM

Practice name: [Practice name]
Address: [Practice address]
Phone: [Practice phone] Email: [Practice email]

Please fill in this form before your first visit. If a question doesn't apply to you, write "N/A". We use the information on this form for your treatment, for payment and for running the practice, as described in our Notice of Privacy Practices (if the practice issues one), and in other ways only as the law allows or requires.

1. Patient information

Full legal name: [First, middle, last]
Preferred name: [Preferred name]
Date of birth: [date]
Address: [Street, city, state, ZIP]
Mobile phone: [phone] Other phone: [phone]
Email: [email]

Preferred way to contact you:
☐ Mobile call ☐ Text message ☐ Email ☐ Other: [describe]

May we leave a detailed voicemail about your appointments? ☐ Yes ☐ No

If the patient is a minor or has a legal representative:
Parent, guardian or representative name: [full name]
Relationship to patient: [relationship]
Phone: [phone]

2. Emergency contact

Name: [full name]
Relationship: [relationship]
Phone: [phone]

3. Reason for your visit

Who referred you to us? ☐ Physician: [name] ☐ Friend or family ☐ Online search ☐ Other: [describe]

In your own words, what brings you in today?
[Describe the problem or goal]

When did it start? [date or approximate time]
What makes it better? [describe]
What makes it worse? [describe]

Rate your current pain or discomfort (0 = none, 10 = worst imaginable): [0 to 10]

4. Insurance or payment

☐ I will use insurance ☐ I will pay myself (self-pay)

If using insurance:
Insurance company: [carrier name]
Member ID: [ID number]
Group number: [group number]
Policyholder name: [full name]
Policyholder date of birth: [date]
Relationship to patient: ☐ Self ☐ Spouse or partner ☐ Parent ☐ Other: [describe]

5. Assignment of benefits and authorization to bill insurance (optional)

Practice: keep this section only if you bill insurance on the patient's behalf. Delete it if you are self-pay only.

☐ I authorize [practice name] to submit claims to my insurance company for services I receive, and to release to my insurer the information it needs to process those claims.

☐ I assign to [practice name] the insurance benefits otherwise payable to me for those services, so my insurer can pay the practice directly.

I understand that I remain responsible for any amount my insurer does not pay, as described in the practice policies below. This authorization stays in effect until I cancel it in writing, and cancelling it does not affect claims already sent.

6. Health history

Primary care provider: [name and phone]

Current medications and supplements (name and dose):
[List, or write "None"]

Allergies (medications, latex, oils, foods or other):
[List, or write "None known"]

Surgeries or hospital stays, with approximate dates:
[List, or write "None"]

Please check any that apply now or in the past:
☐ High or low blood pressure
☐ Heart condition or pacemaker
☐ Blood clots
☐ Diabetes
☐ Seizures
☐ Osteoporosis
☐ Recent fracture, sprain or injury
☐ Joint replacement or metal implants
☐ Cancer
☐ Pregnancy (current)
☐ Skin condition or open wounds
☐ Numbness or tingling
☐ Other: [describe]

Is there anything else you'd like us to know about your health or your comfort during treatment?
[Describe]

7. Practice policies

Appointments and cancellations. Please give us at least [number] hours' notice if you need to cancel or reschedule. Late cancellations or missed appointments may be charged [$ amount or policy].

Payment. Payment for your share of the cost is due [at the time of service / other terms]. If we bill your insurance, you remain responsible for any amount your insurer doesn't pay, including copays, deductibles and non-covered services.

Communication. We may contact you by the method you chose in Section 1 to confirm, remind you about or reschedule appointments.

Changes to your information. Please tell us if your contact details, insurance, medications or health change.

☐ I have read and agree to the practice policies above.

8. Acknowledgment of privacy notice

☐ I received a copy of this practice's Notice of Privacy Practices, or was offered one.

☐ This practice has told me it does not issue a Notice of Privacy Practices. (Leave for the practice to complete if this applies.)

9. Consent to evaluation

I agree to an initial evaluation by [practice name] and its providers. I understand I may ask questions at any time and may stop the evaluation or any treatment whenever I choose. Any specific treatment or procedure will be explained to me, and I may be asked to sign a separate consent for it.

10. Accuracy of information

I confirm that the information on this form is true and complete to the best of my knowledge. I will tell the practice if anything changes.

I agree this form may be signed electronically, and an electronic signature has the same effect as a handwritten one.

Signatures

Patient
Signature: ______________________________
Name: [full name]
Date: [date]

Parent or Guardian (if the patient is a minor)
Signature: ______________________________
Name: [full name]
Date: [date]

If a legal representative other than a parent or guardian is signing for the patient, write their name and relationship here: [full name and relationship]

For office use only: Reviewed by [staff name] on [date].

Quick answers

What is a patient intake form?

It's the form a new patient or client fills in before their first visit. It collects contact details, emergency contacts, insurance or payment information, health history and the patient's consent to practice policies.

Does HIPAA apply to my intake forms?

HIPAA applies to covered entities and their business associates. A health care provider is a covered entity only if it transmits health information electronically in connection with a standard transaction, such as billing insurance electronically, so a cash-only practice may or may not be covered. Check the HHS definition or ask a compliance professional.

Can a patient sign an intake form electronically?

Generally yes. Federal law and state laws give electronic signatures the same effect as handwritten ones for most documents. If your practice is a HIPAA covered entity, the e-signature tool that stores the form must be one that will sign a business associate agreement with you.

Can I use this template for massage or counseling clients?

Yes. It's written for small practices in general. Delete the sections you don't need (a massage therapist may not need insurance details) and add questions your profession or state board expects.

Sources

This template and guide are general information, not legal advice. Laws vary by state; for anything important, have a lawyer licensed where you are review it.

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